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Is HIV Counseling and Testing Effective for Prevention?

While voluntary HIV counseling and testing has been demonstrated to be useful for care and support, the effectiveness of counseling and testing for prevention has not been conclusively demonstrated [1-6]. There have been very few studies of the effectiveness of counseling and testing for prevention, and even fewer randomized trials [7-8], despite repeated calls for controlled studies[1,6,9]. While speculation continues regarding the potential usefulness of counseling and testing despite its relatively high cost, there are currently insufficient data to determine either the efficacy or the true cost of the intervention in relation to the number of infections that could be prevented by it (cost-effectiveness). Arguments in favor of more widespread HIV testing and counseling include that counseling and testing provides an opportunity for education and behavior change and that knowledge of serostatus allows individuals to plan, make important life decisions and to seek care and support [10]. On the other hand, HIV counseling and testing is an expensive intervention compared to health education and other potentially effective prevention strategies. In addition, there are potentially negative social consequences of counseling and testing including family and relationship disruption, sexual violence, stigma and discrimination [11-12]. The Voluntary HIV Counseling and Testing Efficacy Study was a clinical trial conducted in 1995-1997 to test the effectiveness and consequences of Voluntary HIV Counseling and Testing for the prevention of new HIV infections. This is an important policy issue, particularly in countries where health care resources are limited. More specifically the purpose of the study was to determine if counseling and testing, whether given to individuals or couples, might be effective in reducing risk behavior for the sexual transmission of HIV.

References

[1] Higgins DL, Galavotti C, O'Reilly K, et al. Evidence for the Effects of HIV Antibody Counseling and Testing on Risk Behaviors. JAMA 1991; 266:2419-2429. [2] DeZoysa I, Phillips KA, Kamenga MC, et al. Role of HIV counseling and testing in changing risk behavior in developing countries. AIDS 1995: S95-S101. [3] Landis SE, Earp JL, Koch GG. Impact of HIV Testing and Counseling on subsequent sexual behavior. AIDS Education and Prevention; 1992; 4:61-70. [4] Zenilman JM, Erickson B, Fox R, Reichart CA, Hook III EW. Effect of HIV posttest Counseling on STD incidence. JAMA 1992; 267:843-845. [5] Otten Jr MW, Zaidi AA, Wroten JE, Witte JJ, Peterman TA. Changes in Sexually Transmitted Disease Rates after HIV Testing and Posttest Counseling, Miami 1988 to 1989. American Journal of Public Health 1993; 83:529-533. [6] Beardsell S. Should wider HIV testing be encouraged on the grounds of HIV prevention? AIDS Care 1994; 6:5-19. [7] Wenger NS, Linn LS, Epstein M, Shapiro MF. Reduction of High-Risk Sexual Behavior among Heterosexuals Undergoing HIV Antibody Testing: A Randomized Clinical Trial. American Journal of Public Health 1991; 81:1580-1585. [8] Wenger NS, Greenberg JM, Hilborne LH, Kusseling F, Mangotich M, Shapiro MF. Effect of HIV Antibody Testing and AIDS Education on Communication about HIV Risk and Sexual Behavior. Annuals of Internal Medicine 1992; 117:905-911. [9] Phillips KA & Coates TJ. HIV counseling and testing: research and policy issues. AIDS Care 1995; 7:115-124. [10] Müller O, Barugahare L, Schwartländer B, et al. HIV prevalence, attitudes and behavior in clients of a confidential HIV testing and counseling center in Uganda. AIDS 1992; 6:869-874. [11] Colebunders R & Ndumbe P. Priorities for HIV testing in developing countries? The Lancet 1993; 342:601-602. [12] van der Straten A, King R, Grinstead O, Serufilira A, Allen S. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995; 9:935-944.

While you are setting up your equipment, getting the consent form, etc. take note of the surroundings for your field notes.

1. I’d like you to think back to the last time you got an HIV test. Take a minute to remember everything you can about it and then tell me the whole story. Starting from what led up to the test, why you went to get it, where it was done and then how you felt afterwards?

If they have never tested, skip to question # 6: Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for HIV Testing: Motivation: including why they decided to test, whether strictly voluntary, coerced or mandatory testing (prison, hospital), where they found out about testing/test site Location: Where was the test site? Procedures: Describe the actual test? (blood/Orasure) Who administered? How was the counseling? What was discussed in counseling? (Probe for discussion of risk behaviors, results, follow-up appointment) How did you feel after you left? Confidentiality: avoid using the words "confidential" or "anonymous" Were you concerned about privacy at all? (Probe for name or number given, familiar test site, familiar test counselor/administrator) Waiting Period: How was the waiting period? Tell me about any changes that occurred during this time period. Did you talk to anyone about HIV and/or the test during the waiting period? Results: When did you go back for results? IF didn’t get results ask why. If had another test where did get results, what was different this time? Where did you go for results? Who gave them? (probe for familiarity with results counselor) How was the result explained/presented to you? What were your results? Was this the result you were expecting? Why? How did you feel after receiving the results? What was discussed after you received the results? (probe for discussions around risk, 6 month window period, referrals given, IF NEGATIVE — ways to stay negative, any plans made to stay negative) Was talking to them useful/helpful? Did you just want to get out of there? Who did you share your results with? 2. How did this compare to other tests you’ve had, did you like it or not? Was it typical of other tests? 3. After this HIV test, did anything change in your life? (drug use, sex, views on risk) If yes, explain what changed. If NO ask: 4. Have you ever had an HIV test that caused you to change your beliefs or behaviors? If yes, please explain what changed. (Probe for what aspect of C&T caused the change; i.e. was it the risk assessment counseling, or receiving the test results) 5. Is there anything [else] that caused you to change your beliefs or behaviors? (i.e. drug use, sex, views on risk) If yes, please explain what it was, and what changed. 6. Have you ever thought about testing/or been approached about testing? What happened? How did you hear about it? Why did you decide not to test? What do you think would happen if you did test?

Now I’d like to ask you a few more general questions about HIV testing. If they have already discussed their testing pattern above skip 1,2 & 3. 1. How many times have you tested in your life? 2. How often do you test? 3. Do you test regularly? If so, why?

This next section is very general. We are just trying to get a sense of people’s everyday lives. 1. Describe yesterday. What did you do when you got up in the morning until you went to bed? Content Areas for Daily Life: Location(s) Who respondent interacted with during the day Drug Use Resources: eating, getting money Time frames (what time did they get up, what time to bed, etc.) 2. How, in any way, was this different from a typical day?

I have a couple general questions about drugs and then I’d like to ask you more specifically about the last time you used.1. What kinds of drugs do you use now? Probe for all drugs, including alcohol and those used sporadically 2. When do you use and how much? Ask for each drug mentioned above 3. Can you describe to me what happened the last time you used. Tell me the whole story from when it began until where you think it ended. I’d like to know who you were with, what you used, etc. Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for Drug Narrative: In this section we want to get at settings, people, and social and physical conditions which shape use; decisions and rules, spoken and tacit. Before Using: How were you feeling/What kind of mood were you in? What was going on at the time? Buying and preparing: Time and place. How were drugs procured? Who got them? Who paid? How did you get money for the drugs/buy in? If didn’t have money, how did you get your portion? Who was there? What are your relationships with these people? Who prepared drugs, how? How were drugs measured? Probe for using ONE syringe to divide up drugs into other syringes— was the loader’s syringe new or used; were receivers’ syringes new or used. Who or what determined how much each person got? Taking: How did you take the drugs (inject self, injected by another person, smoke, snort) Where did you get the (pipe, works)? Whose (rigs, pipe) did you use? Who went first (second, third, etc.) and why? Afterwards: How did you feel, what did you do afterwards? Did you need any other drugs to come down? 4. How, in any way, was this different from your usual experience using? 5. How does your drug use fit into your sex life? How does your drug use impact your sex life? Probe for drugs used before, during and after sex.

Let me ask you a few general questions about your relationships. 1. Do you currently have a steady partner(s) (girlfriend, boyfriend, husband, wife, etc.)? If so, tell me about her/him or them? Individual characteristics of their partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Probe around past sexual experiences with this partner. What attracted you to her/him? What did you like about her/him? (if appropriate)

Now I would like to ask some personal questions about your sexual behavior. We realize that this is a very personal subject, but your answers are very important to our research. Your answers will remain completely confidential and remember names will not be attached to any of this information. 1. I would like to talk about the last time you had sex with someone without a condom. When was that? NOTE: This includes when a condom broke and when there was dipping. 2. Could you think back now and try to remember as much as you can about that time, and tell me the story of how it happened? Try to remember when it happened, who you were with, what you were doing and how you felt. Let interviewee describe the episode. Listen for answers to each of the following questions. Once Interviewee's story is told, probe for any questions not answered. Content Areas for Sexual Interactions: Sexual partner: Individual characteristics of this sex partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Past sexual experiences with this partner What attracted you to him/her? (if appropriate) Before Sex: What was going on at that time? How did it happen? (When did it happen?, who initiated?, where were you?) How were you feeling? (Were you expecting to have sex? Did either one of you talk about it first? What were you hoping to get out of it?) Sexual Events: What happened? (types of sex: anal, oral, vaginal, mutual masturbation, digital, etc.) What determined the kinds of sex you had? (active vs. passive roles, verbal vs. nonverbal c communication, payment, consent, etc.)  How did you make a decision to NOT use a condom?/Why didn’t you use condoms? Birth control method of any kind used Using (Drugs): Drugs or alcohol used by you or this sex partner before, during or after having sex. (Injected drugs/non-injected drugs/alcohol; levels of intoxication) What did using have to do with this sexual encounter? (sex/drug exchanges, drugs enhancing sex, sex enhancing drug, etc.) HIV/AIDS: Issue of HIV ever discussed (Your status? Partner’s status? If so, how? Before or after sex?) If not discussed, then what did you believe (or assume)? Before or after sex? How did knowing or not knowing your partner’s HIV status affect having sex this time. After Sex: Thinking back over this particular experience, is there anything that you would have wanted to happen differently? Tell me about that. Generalizability - Typical or unusual compared to most of other sexual interactions Relationship potential - Someone you wanted to see again? To have sex with again? 3. How was this different from your usual experience having sex without a condom? 4. How was this different from the last time you had sex WITH a condom? 5. Thinking about when you have sex in general, what makes it easier to use condoms/protection with your partners? (Probes: nature of relationship; how long they knew their partner; serostatus) 6. Thinking about when you have sex in general, what are some of the reasons you haven’t used condoms/protection? 7. How are these situations (using a condom verses not using a condom) different. 8. How is having sex with your "steady partner" (whatever term interviewee uses) different from having sex with others, such as casual partners, one-night stands or tricks?

Desde el inicio de la epidemia, el VIH ha azotado a los hombres y mujeres negros radicados en EE.UU. A pesar de componer sólo el 12% de la población femenina del país, en el 2006 las mujeres negras representaban el 61% de los casos nuevos entre mujeres. Se diagnostica el VIH a mujeres negras con 15 veces más frecuencia que a mujeres caucásicas. Las mujeres negras también tienen altas tasas de infecciones transmitidas sexualmente (ITS), lo cual puede promover la transmisión del VIH. En el 2006, la tasa de clamidia entre mujeres negras era 7 veces mayor, la de gonorrea 14 veces mayor y la de sífilis 16 veces mayor que entre mujeres caucásicas. Estas cifras y estadísticas no terminan de revelar toda la riqueza y diversidad de las vidas de las mujeres negras, un grupo que abarca a oficinistas y obreras, cristianas y musulmanas, habitantes de áreas urbanas y de suburbios, descendientes de esclavos e inmigrantes caribeñas recién llegadas. Ellas trabajan, estudian, crían a sus familias, se enamoran. El VIH entre las mujeres negras no se debe exclusivamente a su conducta individual, sino a un sistema complejo de aspectos sociales, culturales, económicos, geográficos, religiosos y políticos los cuales se entrelazan para afectar a su salud.

El abuso sexual infantil (ASI) tiene muchas definiciones, pero en esta hoja informativa nos referimos al contacto corporal no deseado antes de los 18 años, que es la edad en que se considera que una persona puede dar su consentimiento para tener contacto sexual. El ASI es una experiencia dolorosa a muchos niveles que puede tener, posteriormente, efectos profundos y devastadores en el desarrollo psicológico, psicosocial y emocional. Las experiencias de ASI pueden variar respecto a: duración (varios incidentes con el mismo agresor), grado de fuerza/coerción o grado de intrusión física (desde una caricia, a la penetración digital o al sexo oral, anal o vaginal intentado o consumado). La identidad del agresor/a (que podría ser un desconocido, una persona de confianza o un familiar) también puede influir en las consecuencias a largo plazo para las víctimas. Lo que distingue el ASI de la experimentación sexual exploratoria es el contacto indeseado o forzado o la clara desproporción de poder; comúnmente, se determina como agresor/a alguien que resulte por lo menos 5 años mayor que la víctima. El número de abusos sexuales infantiles excede el número de casos reportados a las autoridades. Se calcula que la prevalencia del ASI en EE.UU. es del 33% entre chicas menores de 18 años y del 10% entre chicos menores de 18 años. Los hombres son considerablemente menos propensos a reportar un incidente de ASI que las mujeres. La probabilidad de que el ASI ocurra aumenta en familias que sufren mucha tensión. Los niños están en riesgo de ser abusados sexualmente en familias que padecen estrés, pobreza, violencia y consumo de alcohol o drogas y cuyos padres y parientes tienen antecedentes de ASI.

HIV+ persons confront a unique set of challenges and chronic stressors, including stigmatization, alienation from family and friends, complex treatment regimens, and, often, debilitating side effects as they attempt to manage the psychologic and physiological consequences of their condition. For persons living with HIV, elevated distress and low social support take on added importance because they can accelerate disease progression. Helping HIV+ people to reduce stress and adhere to their medical care may in turn help to reduce their risky behavior. The ability to cope successfully with a chronic illness such as HIV disease is influenced by a number of social and psychological factors. Stress and coping theory provides a framework for studying these factors and for intervention. Coping research draws attention to the co-occurrence of positive and negative psychological states and recognizes the importance of encouraging coping processes that help to sustain positive psychological states in the context of stress. We evaluated a coping intervention, Coping Effectiveness Training (CET), designed to assist HIV+ gay men in sustaining psychological health despite the ongoing stress associated with HIV infection. The study was a randomized clinical trial of an innovative, theory-based coping intervention. The research questions addressed the problems of maintaining intervention effects, evaluating intervention effects on quality of life, health care utilization and adherence to medical care, and testing new advances in stress and coping theory.